Acute ischemic thalamic infarct resulting in acute mania, impulsivity and chorea.
A 79-year-old man presented with choreiform movements on his left side, impaired balance, and acute impulsivity. Given the acuity of the changes, an MRI of the brain was obtained, which showed an acute infarct within the anterior right thalamic nucleus extending to the genu and posterior limb of the internal capsule. He was medically stable upon transferring to the acute rehabilitation unit, but continued to demonstrate choreiform movements, impulsivity, and inappropriate behavior. He required an interdisciplinary approach while on the rehabilitation unit, which included physiatry, neurology, and psychiatry. The patient required a mood stabilizer and an anti-psychotic to control his choreiform movements. These medications in addition to an interdisciplinary rehabilitation approach resulted in a successful discharge home with control of his symptoms.
Cases of post-stroke movement disorders and mania have been reported, but usually in different areas of the brain compared to this patient. Most cases are self-limited and resolve within 12 months. Common characteristics found in patients with post-stroke mania include male gender, a right cerebral infarct, and no history of psychiatric disorders. However, the literature mentions very little on the rehabilitation of such patients and the management of their symptoms. Additionally, there is little evidence guiding pharmacologic therapy for movement disorders and mania after strokes, but this patient’s course exhibits that treatment is effective under the guidance of multiple disciplines over the course of several months.
Post-stroke movement disorders and mania are sparsely described in the literature, and information regarding the course of these patients through rehabilitation is limited. This case highlights the continued need to define effective treatment strategies for these stroke patients. Also, it emphasizes the need to collaborate effectively with multiple disciplines in order to achieve the best outcome for the patient.
Jessica Casey– Medical School Student, University of Minnesota Medical School
Christopher Meserve– Resident Physician, University of Minnesota
Michael Nguyen– Resident Physician, University of Minnesota
Jeremy Adam– Medical Director of Stroke Rehabilitation, Minneapolis VA Medical Center